Citation Nr: 9830867
Decision Date: 10/16/98 Archive Date: 10/21/98
DOCKET NO. 97-28 309 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Detroit,
Michigan
THE ISSUE
Entitlement to service connection for an upper respiratory
disorder.
REPRESENTATION
Appellant represented by: Military Order of the Purple
Heart
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
D. J. Drucker, Associate Counsel
INTRODUCTION
The veteran had active military service from January 1980 to
January 1983 and from September 1988 to January 1994. This
matter comes to the Board of Veteransí Appeals (Board) on
appeal from a June 1997 rating decision of the Department of
Veterans Affairs (VA) Regional Office (RO) in Detroit,
Michigan.
In a March 1997 statement, the veteran raised a claim for a
temporary total rating and in an August 1997 statement, she
asserted a claim for entitlement to service connection for
Bellís Palsy. As these matters have apparently not as yet
been considered by the RO, they are referred back to the RO
for appropriate action.
REMAND
The veteran asserts that she has an upper respiratory
disorder that had its origins during her second period of
active service, when she was stationed in the Persian Gulf.
Private medical records indicate that in November 1995, she
underwent a right upper lobe bronchoscopy that showed
nonspecific fibrosis with mild inflammation. A March 1996
computed tomography report showed a large central pulmonary
embolus in the right pulmonary artery.
According to private medical records dated in 1997, the
veteran gave physicians a history of being stationed in Saudi
Arabia, in a quarter masters position as a warehouse
supervisor. In March 1991, she said she was treated as an
outpatient for presumed pneumonia characterized by shortness
of breath, productive cough and dyspnea without fever, she
received antibiotics for 30 days and, intermittently, she
noted blood tinged sputum. Thereafter, she had a productive
cough with marked decrease in exercise tolerance. In July
1991, the veteran returned to Fort Lee, Virginia, and was
treated intermittently with antibiotics for similar symptoms.
From June 1992 to January 1994, she was stationed in Germany
and in 1993 she was diagnosed with Bellís Palsy.
A March 1997 private operative report shows that the veteran
underwent a right thoracotomy and biopsy of the upper lobe.
Diagnoses included interstitial pulmonary fibrosis and
organizing pneumonitis. In a March 1997 statement, Kevin O.
Leslie, M.D., diagnosed the veteran with right lung, upper
lobe, open biopsy, and pleural and parenchymal fibrosis with
patchy hemosiderosis and occlusive vasculopathic changes.
Dr. Leslie could not assign a specific etiology to the
veteran's pulmonary illness.
In a late March 1997 statement, Richard S. Goodstein, D.O.,
said that the veteran was diagnosed with nonspecific pleural
and parenchymal fibrosis with patchy hemosiderosis and
vascular occlusive changes, possibly secondary to a prior
pneumonia or inflammatory response. Dr. Goodstein noted
that, given the veteranís prior history, her lung disorder
was most likely secondary to pneumonitis that she apparently
sustained while in the Gulf. Whether this was viral,
Mycoplasma or possibly secondary to an inhaled irritant such
as hydrocarbon was uncertain at the time. It was Dr.
Goldsteinís impression that the etiology of the veteranís
respiratory disorder was secondary to a pneumopathic process
sustained while she was in the Persian Gulf in 1991.
A review of the veteranís claims file reveals that there are
no service medical records for her first period of service.
Further, service records for her second period of service do
not reflect complaints of, or treatment for, a respiratory
disorder in 1991 and 1992 and a copy of the report of her
separation examination is not of record.
In light of all the above, and in the interest of due
process, the Board is of the opinion that the veteranís claim
should be REMANDED to the RO for the following actions:
1. The veteran should be requested to
provide the names, addresses and
approximate dates of treatment for all
health care providers who may possess
additional records pertinent to her
claim. When the requested information
and any necessary authorizations have
been received, the RO should attempt
to obtain copies of all indicated
records and associate them with the
claims file.
2. The RO should, to the extent feasible,
attempt to obtain copies of all the
veteranís service medical records,
including those from her first period
of service. The RO should attempt to
obtain any and all additional service
medical records for the veteranís
second period of service, including a
separation examination report, and
records of pulmonary complaints or
treatment from March 1991, while she
was stationed in Saudi Arabia or other
Persian Gulf countries, to July 1991
and thereafter, when she was stationed
at Fort Lee, Virginia. Additionally,
the RO should also obtain a copy of
the veteranís service personnel
records, including her DA 20 file.
3. Upon completion of the above, the
veteran should be scheduled for a VA
examination by a specialist in
pulmonary medicine to determine the
nature and extent of any current upper
respiratory disabilities found to be
present. A detailed medical history
relevant to the disability at issue
should be obtained. All indicated
tests and studies should be performed,
and all manifestations of current
disability should be described in
detail. The VA examiner is requested
to review the claims folder and
provide an opinion as to whether it is
at least as likely as not that the
veteran has an upper respiratory
disorder or other pulmonary pathology
that had its onset in or is otherwise
related to her period of active duty,
including her service in the Persian
Gulf. A complete rationale should be
given for all opinions and conclusions
expressed. The veteranís claims file,
including her service medical records,
VA examination reports and private
medical records and statements, should
be reviewed by the VA examiner prior
to the examination.
4. Thereafter, the RO should undertake
any other development deemed warranted
and readjudicate the issue of
entitlement to service connection for
an upper respiratory disorder, to
include consideration of 38 C.F.R.
ß 3.317 (1997).
If the benefits sought on appeal are not granted to the
veteranís satisfaction or if a timely notice of disagreement
is received with respect to any other matter, the veteran and
her representative should be furnished a supplemental
statement of the case on all issues in appellate status, and
be afforded a reasonable opportunity to respond before the
record is returned to the Board for further review. The
veteran should be informed of the requirements to perfect an
appeal with respect to any new issues addressed in the
supplemental statement of the case. By this remand, the
Board intimates no opinion as to any final outcome warranted.
No action is required of the veteran until she is otherwise
notified by the RO.
WAYNE M. BRAEUER
Member, Board of Veterans' Appeals
Under 38 U.S.C.A. ß 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. ß 20.1100(b)
(1997).
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